Is insurance a viable strategy for promoting SRH? Experiences from Bolivia, Egypt and Rwanda

1. Is insurance a viable strategy for promoting SRH? Experiences from Bolivia, Egypt and Rwanda Tania Dmytraczenko Abt Associates Inc., Partners for Health Reformplus Leeds, UK September 8-11, 2003

2. Outline of Presentation • Background • Bolivia: • Health policy strategy in Bolivia • Results from Bolivia • Contributions and next steps • Rwanda: • Health policy strategy in Rwanda • Results from Rwanda • Contributions and next steps • Concluding remarks

3. Poverty and Health Bolivia • Poverty • USD 950 per capita income • Maternal Mortality Rate • 371 per 100,000 live births Rwanda • Poverty • USD 100 mean monetary consumption expenditures per capita per year • Maternal Mortality Rate • 1071 per 100,000 live births

4. Bolivia: Equity in Access to Institutional Care by Pregnant Women Source: DHS Bolivia, 1998

5. Rwanda: Equity in Access to Curative Care for Women User Fee System Source: Household and Living Condition Survey 1999/2001

6. The common thread between Bolivia and Rwanda • Recognition that financial constraints are a barrier to access • Health policy strategies aimed at reducing maternal and child mortality by reducing economic barriers to access • Health insurance as an alternative to user fees

7. Health Insurance in Bolivia • Insurance for Mothers and Children (SNMN) – mid 1996 • Women and children under 5 receive treatment free-of-charge for set services • MOH facilities at all levels, some social security hospitals, very few NGOs • Financed from general taxation • 20% of government revenues transferred to municipalities • 3.2% of municipal funds (for investment) earmarked for health • Facilities are reimbursed on a per service basis by municipal government • Drugs, supplies, hospitalization, lab exams

8. Evolution of the Insurance Program • Basic Health Insurance (SBS) – 1999 • Beneficiary population broadened • Package of benefits expanded • Participating facilities increased • Social security facilities • Health Insurance for Mothers and Children (SUMI) – 2003 • Return to original target population • Universality of services covered • Facilities still reimbursed on a per service basis by municipal government • Increase in earmark for health • SMNM: 3.2% • SBS: 6.4% • SUMI: 10%

9. Increased deliveries in health facilities

10. Increased deliveries in health facilities in rural areas

11. Increase in deliveries attended by skilled personnel

12. Increase in deliveries attended by skilled personnel

13. At least some of the increase can be attributed to the Insurance Program Source : SNIS, MSPS

14. Contributions of Health Insurance in Bolivia • Utilization of maternal and child health services increased • The rural poor are using insurance services • Government promotional efforts informed the public • Primary level facilities increased drug availability • Utilization of public health infrastructure increased

15. Next Steps In Bolivia • Some of the increase in public services is due to transfers from the private sector • Address issues related to appropriate public private mix • Costs differ across facility type, but reimbursement rates do not • Differentiate reimbursement rates across the different service delivery levels • Reimbursement rates do not cover labor costs • Issues related to health worker motivation • Free services encourage patients to seek care at higher level facilities • Establish a referral system

16. Increased utilization of higher level facilities

17. Rwanda: Health Policy Strategy • Pilot-Test Micro-Health Insurance in 3 Rural Districts (with 1 million population) • Evaluate Effectiveness of Insurance Function in Improving • Equity in Access and in Health Financing • Sustainability • Community Participation

18. Equity in Access to Care: Sick MHI Members Use Modern Health Facilities at a Higher Rate Across Consumption Quartiles Source: HH-survey

19. Members are more likely to receive professional assistance during delivery

20. Equity in Health Financing: Members Pay Lower Price at Time of Consumption Source: Patient exit interviews

21. Contributions of Micro-Health Insurance in Rwanda • Lifted financial barriers in access to maternal, preventive and curative services • Families with children and women in child-bearing age were most likely to enroll, and have fully benefited from better financial accessibility

22. Next Steps In Rwanda • To respond to the demand of other districts and scale up the prepayment plans nationwide • To expand the benefit package to full district coverage • To subsidize the demand of annual premiums for the poor through a community fund

23. Concluding remarks • Organizational and legal form of health insurance embedded in country’s socio-economic context • Political viability • Design phase is critically important • Appropriate incentives • Adverse selection, moral hazard, cream skimming, etc. • Health worker motivation • Human and organizational capacity building • Monitoring and evaluation

24. Partnerships for Health Reform is implemented by Abt Associates Inc. under contract No. HRN-C-95-00024 with the U.S. Agency for International Development (USAID)